Odontoid Fracture with Accompanying Severe Atlantoaxial Instability in Elderly Patients-Analysis of Treatment, Adverse Events, and Outcome.

(1) Background: In elderly patients with type II odontoid fractures, accompanying severe atlantoaxial instability (AAI) is discussed as a marker possibly warranting more aggressive surgical therapy. This study aimed to characterize adverse events as well as the radiological and functional outcomes of surgical vs. conservative therapy in patients with odontoid fracture and AAI. (2) Methods: Patients aged 65 years and older with type II odontoid fracture and AAI treated were included. AAI was assumed if the mean subluxation across both atlantoaxial facet joints in the sagittal plane was greater than 50%. Data on demographics, comorbidities, treatment, adverse events, radiological, and functional outcomes were analyzed. (3) Results: Thirty-nine patients were included. Hospitalization time was significantly shorter in conservatively treated patients compared to patients with ventral or dorsal surgery. Adverse events occurred in 11 patients (28.2%), affecting 10 surgically treated patients (35.7%), and 1 conservatively treated patient (9.1%). Moreover, 25 patients were followed-up (64.1%). One secondary dislocation occurred in the conservative group (11.1%) and three in the surgical group (18.8%). (4) Conclusions: Despite the potential for instability in this injury, conservative treatment does not seem to lead to unfavorable short-term results, less adverse events, and a shorter hospital stay and should thus be considered and discussed with patients as a treatment option, even in the presence of severe AAI.

Adverse events after surgery for injuries to the subaxial cervical spine: analysis of incidence and risk factors.

PURPOSE: To determine the incidence of severe surgical adverse events (sSAE) after surgery of patients with subaxial cervical spine injury (sCS-Fx) and to identify patient, treatment, and injury-related risk factors. METHODS: Retrospective analysis of clinical and radiological data of sCS-Fx patients treated surgically between 2010 and 2020 at a single national trauma center. Baseline characteristics of demographic data, preexisting conditions, treatment, and injury morphology were extracted. Incidences of sSAEs within 60 days after surgery were analyzed. Univariate analysis and binary logistic regression for the occurrence of one or more sSAEs were performed to identify risk factors. P-values < .05 were considered statistically significant. RESULTS: Two hundred and ninety-two patients were included. At least one sSAE occurred in 49 patients (16.8%). Most frequent were sSAEs of the surgical site (wound healing disorder, infection, etc.) affecting 29 patients (9.9%). Independent potential risk factors in logistic regression were higher age (OR 1.02 [1.003-1.04], p = .022), the presence of one or more modifiers in the AO Spine Subaxial Injury Classification (OR 2.02 [1.03-3.96], p = .041), and potentially unstable or unstable facet injury (OR 2.49 [1.24-4.99], p = .010). Other suspected risk factors were not statistically significant, among these Injury Severity Score, the need for surgery for concomitant injuries, the primary injury type according to AO Spine, and preexisting medical conditions. CONCLUSION: sSAE rates after treatment of sCS-Fx are high. The identified risk factors are not perioperatively modifiable, but their knowledge should guide intra and postoperative care and surgical technique.

Secondary Dislocations in Type B and C Injuries of the Subaxial Cervical Spine: Risk Factors and Treatment.

INTRODUCTION: This study analyzed the incidence of secondary dislocations (sDLs) after surgical stabilization of AO Spine type B and C injuries of the subaxial cervical spine (sCS). MATERIALS AND METHODS: Patients treated for injuries of the sCS from 2010 to 2020 were retrospectively analyzed for the incidence of sDL within 60 days after first surgery. A univariate analysis of variables potentially influencing the risk of sDL was performed. Patients with solitary anterior stabilization underwent subgroup analysis. The treatment of sDLs was described. RESULTS: A total of 275 patients were included. sDLs occurred in 4.0% of patients (n = 11) in the total sample, most frequently after solitary anterior stabilization with 8.0% (n = 10, p = 0.010). Only one sDL occurred after combined stabilization and no sDLs after posterior stabilization. In the total sample and the anterior subgroup, variables significantly associated with sDL were older age (p = 0.001) and concomitant unstable facet joint injury (p = 0.020). No neurological deterioration occurred due to sDL and most patients were treated with added posterior stabilization. sDL is frequent after solitary anterior stabilization and rare after posterior or combined stabilization. DISCUSSION: Patients of higher age and with unstable facet joint injuries should be followed up diligently to detect sDLs in time. Neurological deterioration does not regularly occur due to sDL, and most patients can be treated with added posterior stabilization.

Survival and Clinical Outcomes after Unconstrained Total Knee Arthroplasty for Tibial Plateau Fractures-A Retrospective Study with Minimum 4-Year Follow-Up.

This study investigated survival, complications, revisions, and patient-reported outcomes (PROs) for unconstrained total knee arthroplasty (TKA) in posttraumatic osteoarthritis (PTO) caused by intraarticular tibial plateau fractures with minimum four years follow-up. Forty-nine patients (71.4% male; 58.7 years) were included. Kaplan-Meier analysis was performed with failure defined as TKA removal. Patients without failure underwent pre- and postoperative evaluation (range of motion (ROM), Oxford Knee Score (OKS), Knee Society Score (KSS), anatomical femorotibial angle (aFTA), proximal tibial slope (PTS)) and Short Form-12 (SF-12) Physical (PCS) and Mental Component Summary (MCS) assessment at final follow-up. Fifteen (30.6%) patients had a complication, and eight (16.3%) patients underwent prosthesis removal at median 2.5 years. Cumulative survival rate of TKA was 79.6% at 20 years. A total of 32 patients with a mean follow-up of 11.8 years underwent further analyses. ROM (p = 0.028), aFTA (p = 0.044), pPS (p = 0.009), OKS (p < 0.001) and KSS (p < 0.001) improved significantly. SF-12 PCS was 42.3 and MCS was 54.4 at final follow-up. In general, one third of patients suffer a complication, and one in six patients has their prosthesis removed after TKA for PTO due to tibial plateau fractures. In patients who do not fail, TKA significantly improves clinical and radiographic outcomes at long-term follow-up.

Effect of changing the acquisition trajectory of the 3D C-arm (CBCT) on image quality in spine surgery: experimental study using an artificial bone model.

BACKGROUND: Intraoperative 3D imaging using cone-beam CT (CBCT) provides improved assessment of implant position and reduction in spine surgery, is used for navigated surgical techniques, and therefore leads to improved quality of care. However, in some cases the image quality is not sufficient to correctly assess pedicle screw position and reduction, especially due to metal artifacts. The aim of this study was to investigate whether changing the acquisition trajectory of the CBCT in relation to the pedicle screw position during dorsal instrumentation of the spine can reduce metal artifacts and consequently improve image quality as well as clinical assessability on the artificial bone model. METHODS: An artificial bone model was instrumented with pedicle screws in the thoracic and lumbar spine region (Th10 to L5). Then, the acquisition trajectory of the CBCT (Cios Spin, Siemens, Germany) to the pedicle screws was systematically changed in 5° steps in angulation (- 30° to + 30°) and swivel (- 30° to + 30°). Subsequently, radiological evaluation was performed by three blinded, qualified raters on image quality using 9 questions (including anatomical structures, implant position, appearance of artifacts) with a score (1-5 points). For statistical evaluation, the image quality of the different acquisition trajectories was compared to the standard acquisition trajectory and checked for significant differences. RESULTS: The angulated acquisition trajectory increased the score for subjective image quality (p < 0.001) as well as the clinical assessability of pedicle screw position (p < 0.001) highly significant with particularly strong effects on subjective image quality in the vertebral pedicle region (d = 1.06). Swivel of the acquisition trajectory significantly improved all queried domains of subjective image quality (p < 0.001) as well as clinical assessability of pedicle screw position (p < 0.001). The data show that maximizing the angulation or swivel angle toward 30° provides the best tested subjective image quality. Angulation and swivel of the acquisition trajectory result in a clinically relevant improvement in image quality in intraoperative 3D imaging (CBCT) during dorsal instrumentation of the spine.

Odontoid fracture in geriatric patients - analysis of complications and outcome following conservative treatment vs. ventral and dorsal surgery.

BACKGROUND: Different treatment options are discussed for geriatric odontoid fracture. The aim of this study was to compare the treatment options for geriatric odontoid fractures. METHODS: Included were patients with the following criteria: age ≥ 65 years, identification of seniors at risk (ISAR score ≥ 2), and odontoid fracture type A/B according to Eysel and Roosen. Three groups were compared: conservative treatment, surgical therapy with ventral screw osteosynthesis or dorsal instrumentation. At a follow-up examination, the range of motion and the trabecular bone fracture healing rate were evaluated. Furthermore, demographic patient data, neurological status, length of stay at the hospital and at the intensive care unit (ICU) as well as the duration of surgery and occurring complications were analyzed. RESULTS: A total of 72 patients were included and 43 patients could be re-examined (range: 2.7 ± 2.1 months). Patients with dorsal instrumentation had a better rotation. Other directions of motion were not significantly different. The trabecular bone fracture healing rate was 78.6%. The patients with dorsal instrumentation were hospitalized significantly longer; however, their duration at the ICU was shortest. There was no significant difference in complications. CONCLUSION: Geriatric patients with odontoid fracture require individual treatment planning. Dorsal instrumentation may offer some advantages.

Radiation exposure for pedicle screw placement with three different navigation system and imaging combinations in a sawbone model.

BACKGROUND: Studies have shown that pedicle screw placement using navigation can potentially reduce radiation exposure of surgical personnel compared to conventional methods. Spinal navigation is based on an interaction of a navigation software and 3D imaging. The 3D image data can be acquired using different imaging modalities such as iCT and CBCT. These imaging modalities vary regarding acquisition technique and field of view. The current literature varies greatly in study design, in form of dose registration, as well as navigation systems and imaging modalities analyzed. Therefore, the aim of this study was a standardized comparison of three navigation and imaging system combinations in an experimental setting in an artificial spine model. METHODS: In this experimental study dorsal instrumentation of the thoracolumbar spine was performed using three imaging/navigation system combinations. The system combinations applied were the iCT/Curve, cCBCT/Pulse and oCBCT/StealthStation. Referencing scans were obtained with each imaging modality and served as basis for the respective navigation system. In each group 10 artificial spine models received bilateral dorsal instrumentation from T11-S1. 2 referencing and control scans were acquired with the CBCTs, since their field of view could only depict up to five vertebrae in one scan. The field of view of the iCT enabled the depiction of T11-S1 in one scan. After instrumentation the region of interest was scanned again for evaluation of the screw position, therefore only one referencing and one control scan were obtained. Two dose meters were installed in a spine bed ventral of L1 and S1. The dose measurements in each location and in total were analyzed for each system combination. Time demand regarding screw placement was also assessed for all system combinations. RESULTS: The mean radiation dose in the iCT group measured 1,6 ± 1,1 mGy. In the cCBCT group the mean was 3,6 ± 0,3 mGy and in the oCBCT group 10,3 ± 5,7 mGy were measured. The analysis of variance (ANOVA) showed a significant (p < 0.0001) difference between the three groups. The multiple comparisions by the Kruskall-Wallis test showed no significant difference for the comparison of iCT and cCBCT (p1 = 0,13). Significant differences were found for the direct comparison of iCT and oCBCT (p2 < 0,0001), as well as cCBCT and oCBCT (p3 = 0,02). Statistical analysis showed that significantly (iCT vs. oCBCT p = 0,0434; cCBCT vs. oCBCT p = 0,0083) less time was needed for oCBCT based navigated pedicle screw placement compared to the other system combinations (iCT vs. cCBCT p = 0,871). CONCLUSION: Under standardized conditions oCBCT navigation demanded twice as much radiation as the cCBCT for the same number of scans, while the radiation exposure measured for the iCT and cCBCT for one scan was comparable. Yet, time effort was significantly less for oCBCT based navigation. However, for transferability into clinical practice additional studies should follow evaluating parameters regarding feasibility and clinical outcome under standardized conditions.

Analysis of the cost-efficiency of the vascular impulse technology (VIT) in the perioperative management of complex ankle fractures: results of a prospective randomised controlled trial.

INTRODUCTION: Posttraumatic swelling causes a delay in surgery, a prolonged hospital stay and a higher risk of complications. Thus, soft tissue conditioning following complex ankle fractures is of central importance in their perioperative management. Since the clinical benefit of VIT usage on the clinical course has been shown, it should now be investigated whether it is also cost-efficient in doing so. MATERIALS AND METHODS: Included are published clinical results of the prospective, randomised, controlled, monocentric VIT study that have proven the therapeutic benefit in complex ankle fractures. Participants were allocated in a 1:1 ratio into the intervention group (VIT) and the control group (elevation). In this study, the required economic parameters of these clinical cases were collected on the data of the financial accounting and an estimation of annual cases had been performed to extrapolate the cost-efficiency of this therapy. The primary endpoint was the mean savings (in €). RESULTS: Thirty-nine cases were studied in the period from 2016 to 2018. There was no difference in the generated revenue. However, due to lower incurred costs in the intervention group, there were potential savings of about €2000 (pITT = 0.073) to 3000 (pAT = 0.008) per patient compared to the control group with therapy costs decreasing as the number of patients treated increases from €1400 in one case to below €200 per patient in 10 cases. There were 20% more revision surgeries in the control group or 50 min more OR time, respectively, and an increased attendance by staff and medical personnel of more than 7 h. CONCLUSIONS: VIT therapy has been shown to be a beneficial therapeutic modality, but it is so not only in regard to soft-tissue conditioning but also cost efficiency.

Vascular impulse technology versus elevation for reducing the swelling of upper and lower extremity joint fractures.

Soft-tissue conditioning due to posttraumatic oedema after complicated joint fractures is a central therapeutic aspect both pre- and postoperatively. On average, 6-10 days pass until the patient is suitable for surgery. This study compares the decongestant effect of vascular impulse technology (VIT) with that of conventional elevation. In this monocentric RCT, 68 patients with joint fractures of the upper (n = 36) and lower (n = 32) extremity were included and randomized after consent in a 1:1 ratio. Variables were evaluated for all fractures together and additionally subdivided into upper or lower extremity for better clinical comparability. Primary endpoint was the time in days from hospital admission to operability. Secondary endpoints were total length of stay, oedema reduction, pain intensity, complications, and revisions. The time from admission until operability was reduced by 1.4 (95% CI - 0.4; 3.1) days in the mITT analysis (p = 0.120) and was statistically significant with 1.7 (95% CI 0.1; 3.3) days in the as-treated sensitivity analysis (pAT = 0.038). Significantly less pain and a faster oedema reduction were found in the intervention group. Due to rare occurrences, nothing can be concluded regarding complications and revisions. Administration of VIT therapy did not lead to a significant reduction in time until operability in the whole population but was superior to elevation for soft-tissue conditioning and pain reduction. However, there was a significant reduction by 2.5 days (95% CI 0.7; 4.3) in the subgroup of lower extremity fractures. VIT therapy therefore seems to be a helpful tool in the treatment of posttraumatic oedema after complex joint fractures of the lower and upper extremity, especially in tibial head and lower leg fractures.

[Computer-assisted procedures in orthopedics and trauma surgery-Where do we stand?] / Computergestützte Verfahren in der Orthopädie und Unfallchirurgie ­ wo stehen wir?

Computer-assisted procedures are becoming increasingly more relevant in orthopedics and trauma surgery. The data situation on these systems has improved in recent years but still has a low level of evidence. In particular, data on short-term or medium-term results on the use of these procedures are currently available. These could show that improved precision and reproducibility of the surgical procedures can be achieved by the use of computer-assisted procedures. Nevertheless, there is still no recommendation in the current guidelines for routine use.

Is the postoperative pedicle screw position after dorsal instrumentation with or without intraoperative cone beam CT imaging worse in patients with obesity than in normal-weight patients?

BACKGROUND: Intraoperative cone beam CT (CBCT) imaging in dorsal instrumentation facilitates pedicle screw positioning. However, in patients with obesity, the benefit may be reduced due to artifacts that affect image quality. The purpose of this study was to evaluate whether intraoperative CBCT leads to an improved postoperative screw position compared to conventional fluoroscopy independent of body weight. METHODS: A total of 71 patients (18 patients with a BMI > 30 kg/m2, 53 patients with a BMI < 30 kg/m2) who underwent dorsal instrumentation with intraoperative CBCT imaging were included in study groups one (SG1) and two (SG2). Two control groups (CG1 and CG2) were randomly sampled to include 22 patients with a BMI > 30 kg/m2 and 60 patients with a BMI < 30 kg/m2 who underwent dorsal instrumentation without intraoperative CBCT imaging. The pedicle screw position in postoperative computed tomography was assessed using the Gertzbein-Robbins classification. RESULTS: In SG1 (BMI > 30 kg/m2), a total of 107 (83.6%) pedicle screws showed no relevant perforation (type A + B), and 21 (16.4%) pedicle screws showed relevant perforation (type C - E). In SG2 (BMI < 30 kg/m2), 328 (90.9%) screws were classified as type A + B, and 33 (9.1%) screws were classified as type C - E. In CG1 (BMI > 30 kg/m2), 102 (76.1%) pedicle screws showed no relevant perforation (type A + B), and 32 (23.9%) pedicle screws showed relevant perforation (type C - E). In CG2 (BMI < 30 kg/m2), 279 (76.9%) screws were classified as type A + B, and 84 (23.1%) screws were classified as type C - E. There were significant differences between the values of SG1 and SG2 (p = 0.03) and between the values of SG2 and CG2 (p < 0.0001). CONCLUSION: CBCT imaging in dorsal instrumentation can lead to an improved pedicle screw position among both patients with obesity and normal-weight patients. However, patients with obesity showed significantly worse pedicle screw positions postoperatively after dorsal instrumentation with intraoperative CBCT imaging than normal-weight patients.

Detection of fibular rotational changes in cone beam CT: experimental study in a specimen model.

BACKGROUND: In syndesmotic injuries, incorrect reduction leads to early arthrosis of the ankle joint. Being able to analyze the reduction result is therefore crucial for obtaining an anatomical reduction. Several studies that assess fibular rotation in the incisura have already been published. The aim of the study was to validate measurement methods that use cone beam computed tomography imaging to detect rotational malpositions of the fibula in a standardized specimen model. METHODS: An artificial Maisonneuve injury was created on 16 pairs of fresh-frozen lower legs. Using a stable instrument, rotational malpositions of 5, 10, and 15° internal and external rotation were generated. For each malposition of the fibula, a cone beam computed tomography scan was performed. Subsequently, the malpositions were measured and statistically evaluated with t-tests using two measuring methods: angle (γ) at 10 mm proximal to the tibial joint line and the angle (δ) at 6 mm distal to the talar joint line. RESULTS: Rotational malpositions of ≥ 10° could be reliably displayed in the 3D images using the measuring method with angle δ. For angle γ significant results could only be displayed for an external rotation malposition of 15°. CONCLUSIONS: Clinically relevant rotational malpositions of the fibula in comparison with an uninjured contralateral side can be reliably detected using intraoperative 3D imaging with a C-arm cone beam computed tomography. This may allow surgeons to achieve better reduction of fibular malpositions in the incisura tibiofibularis.

Comparison of three imaging and navigation systems regarding accuracy of pedicle screw placement in a sawbone model.

3D-navigated pedicle screw placement is increasingly performed as the accuracy has been shown to be considerably higher compared to fluoroscopy-guidance. While different imaging and navigation devices can be used, there are few studies comparing these under similar conditions. Thus, the objective of this study was to compare the accuracy of two combinations most used in the literature for spinal navigation and a recently approved combination of imaging device and navigation system. With each combination of imaging system and navigation interface, 160 navigated screws were placed percutaneously in spine levels T11-S1 in ten artificial spine models. 470 screws were included in the final evaluation. Two blinded observers classified screw placement according to the Gertzbein Robbins grading system. Grades A and B were considered acceptable and Grades C-E unacceptable. Weighted kappa was used to calculate reliability between the observers. Mean accuracy was 94.9% (149/157) for iCT/Curve, 97.5% (154/158) for C-arm CBCT/Pulse and 89.0% for CBCT/StealthStation (138/155). The differences between the different combinations were not statistically significant except for the comparison of C-arm CBCT/Pulse and CBCT/StealthStation (p = 0.003). Relevant perforations of the medial pedicle wall were only seen in the CBCT group. Weighted interrater reliability was found to be 0.896 for iCT, 0.424 for C-arm CBCT and 0.709 for CBCT. Under quasi-identical conditions, higher screw accuracy was achieved with the combinations iCT/Curve and C-arm CBCT/Pulse compared with CBCT/StealthStation. However, the exact reasons for the difference in accuracy remain unclear. Weighted interrater reliability for Gertzbein Robbins grading was moderate for C-arm CBCT, substantial for CBCT and almost perfect for iCT.

Development of a New Emergency Medicine Spinal Immobilization Protocol for Pediatric Trauma Patients and First Applicability Test on Emergency Medicine Personnel.

OBJECTIVES: The purpose of this study was to (i) develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) perform an applicability test on emergency medicine personnel. METHODS: A structured search of the literature published between 1980 and 2019 was performed in MEDLINE using PubMed. Based on this literature search, a new Emergency Medicine Spinal Immobilization Protocol for pediatric trauma patients (E.M.S. IMMO Protocol Pediatric) was developed. Parameters found in the literature, such as trauma mechanism and clinical findings that accounted for a high probability of spinal injury, were included in the protocol. An applicability test was administered to German emergency medicine personnel using a questionnaire with case examples to assess correct decision making according to the protocol. RESULTS: The E.M.S. IMMO Protocol Pediatric was developed based on evidence from published literature. In the applicability test involving 44 emergency medicine providers revealed that 82.9% of participants chose the correct type of immobilization based on the protocol. A total of 97.8% evaluated the E.M.S. IMMO Protocol Pediatric as helpful. CONCLUSIONS: Based on the current literature, the E.M.S. IMMO Protocol Pediatric was developed in accordance with established procedures used in trauma care. The decision regarding immobilization is made on based on the cardiopulmonary status of the patient, and life-threatening injuries are treated with priority. If the patient presents in stable condition, the necessity for full immobilization is assessed based upon the mechanisms of injury, assessment of impairment, and clinical examination.

Post-operative Use of Cervical Orthoses for Subaxial Cervical Spine Injuries - a Survey-based Analysis at German Spine Care Centres. / Postoperative Anwendung von Zervikalorthesen bei Verletzungen der subaxialen Halswirbelsäule ­ eine umfragebasierte Analyse an deutschen Wirbelsäulenzentren.

INTRODUCTION: There are no evidence-based recommendations for the post-operative treatment and application of soft or rigid cervical collars after operative treatment of injuries of the subaxial cervical spine. Cervical collars can restrict peak range of motion and serve as a reminder to the patient. However, they can also cause pressure ulcers. The aim of this online-based survey among German spine centres was to gain an overview of post-operative treatment and the application of soft or rigid cervical collars after surgical treatment of injuries of the subaxial cervical spine. MATERIALS AND METHODS: An online-based survey was conducted among 59 spine centres certified by the German Spine Society. It comprised seven items and the option of adding remarks in the form of open-ended responses. RESULTS: The return rate was 63% (37 out of 59). Of the 37 analysed spine centres, 51% routinely apply a cervical collar post-operatively, 27% apply a soft and 16% a rigid cervical collar, 8% sequentially apply first a rigid and later a soft cervical collar. Less than half of the spine centres (43%) routinely use no cervical collar. Rigid collars are applied for more than 6 weeks and soft collars up to 6 weeks at some spine centres. Standardised post-operative treatment plans are common. The selection of the post-operative treatment plan depends primarily on the type of injury and method of operation and partly on patient age and bone quality. The satisfaction of German spine centres with the current handling of post-operative treatment of subaxial cervical spine injuries is high. DISCUSSION: The post-operative treatment of injuries of the subaxial cervical spine at German spine centres is heterogeneous, and the evidence on advantages and disadvantages of the post-operative application of cervical collars is insufficient. Planning and implementation of randomised controlled clinical trials in subaxial cervical spine injuries is challenging.

Development and first application testing of a new protocol for CT-based stability evaluation of the injured upper cervical spine.

PURPOSE: For trauma surgeons, the evaluation of the stability of the upper cervical spine may be demanding. The aim of this study was to develop a protocol for decision-making on upper cervical spine stability in trauma patients based on established parameters obtained by CT imaging as well as testing the protocol by having it applied by trauma surgeons. METHODS: A structured literature search on upper cervical spine stability was performed. The best evaluated instability criteria in CT imaging were determined. Based on these parameters a protocol for stability evaluation of the injured upper cervical spine was developed. A first application testing was performed. In addition to the assessment of instability, the time required for the assessment was analyzed. RESULTS: A protocol for CT-based stability evaluation of the injured upper cervical spine based on the current literature was developed and displayed in a flow chart. Testing of the protocol found the stability of the cervical spine was correctly assessed in 55 of 56 evaluations (98.2%). In one test run, a stable upper cervical spine was judged to be unstable. Further analysis showed that this case was based on a measurement error. The assessment time of CT-images decreased significantly during repeat application of the protocol (p < 0.0001), from 336 ± 108 s (first case) to 180 ± 30 s (fourth case). CONCLUSION: The protocol can be applied quickly and safely by non-specialized trauma surgeons. Thus, the protocol can support the decision-making process in CT-based evaluation of the stability of the injured upper cervical spine.

Evaluation of external stabilization of type II odontoid fractures in geriatric patients-An experimental study on a newly developed cadaveric trauma model.

BACKGROUND: Along with the growing geriatric population, the number of odontoid fractures is steadily increasing. However, the effectiveness of immobilizing geriatric odontoid fractures using a cervical collar has been questioned. The aim of the present study is to analyze the physiological and pathological motion in odontoid fractures and to assess limitation of motion in the cervical spine when applying a cervical collar. METHODS: Motion analysis was performed with wireless motion tracker on unfixed geriatric human cadavers. First, a new geriatric type II odontoid fracture model was developed. In this model, the type II odontoid fracture is operated via a transoral approach. The physiological and pathological flexion and lateral bending of the cervical spine resulting from this procedure was measured. The resulting motion after external stabilization using a cervical collar was analyzed. RESULTS: The new geriatric type II odontoid fracture model was successfully established using seven unfixed human cadavers. The pathological flexion of the cervical spine was significantly increased compared to the physiological flexion (p = 0.027). Furthermore, the flexion was significantly reduced when a cervical collar was applied. In case of flexion the mean remaining motion was significantly reduced (p = 0.0017) from 41° to 14°. For lateral bending the mean remaining motion was significantly reduced (p = 0.0137) from 48° to 18°. CONCLUSIONS: In case of type II odontoid fracture, flexion and lateral bending of the cervical spine are increased due to spinal instability. Thus, if an odontoid fracture is suspected in geriatric patients, the application of a cervical collar should always be considered since external stabilization can significantly reduce flexion and lateral bending.

Analysis of remaining motion using one innovative upper airway opening cervical collar and two traditional cervical collars.

The aim of this study was to compare the remaining motion of an immobilized cervical spine using an innovative cervical collar as well as two traditional cervical collars. The study was performed on eight fresh human cadavers. The cervical spine was immobilized with one innovative (Lubo Airway Collar) and two traditional cervical collars (Stifneck and Perfit ACE). The flexion and lateral bending of the cervical spine were measured using a wireless motion tracker (Xsens). With the Weinman Lubo Airway Collar attached, the mean remaining flexion was 20.0 ± 9.0°. The mean remaining flexion was lowest with the Laerdal Stifneck (13.1 ± 6.6°) or Ambu Perfit ACE (10.8 ± 5.8°) applied. Compared to that of the innovative Weinmann Lubo Airway Collar, the remaining cervical spine flexion was significantly decreased with the Ambu Perfit ACE. There was no significant difference in lateral bending between the three examined collars. The most effective immobilization of the cervical spine was achieved when traditional cervical collars were implemented. However, all tested cervical collars showed remaining motion of the cervical spine. Thus, alternative immobilization techniques should be considered.

Cervical Spine Immobilization in Patients With a Geriatric Facial Structure: The Influence of a Geriatric Mandible Structure on the Immobilization Quality Using a Cervical Collar.

INTRODUCTION: Demographic changes have resulted in an increase in injuries among geriatric patients. For these patients, a rigid cervical collar is crucial for immobilizing the cervical spine. However, evidence suggests that patients with a geriatric facial structure require a different means of immobilization than patients with an adult facial structure. This study aimed to analyze the remaining motion of the immobilized cervical spine based on facial structure. MATERIALS AND METHODS: This study was performed on 8 fresh human cadavers. Facial structure was evaluated via ascertaining the mandibular angle by computer tomography. A mandibular angle below 130°, belongs to the adult facial structure group (n = 4) and a mandibular angle above 130°, belongs to the geriatric facial structure group (n = 4). The flexion and lateral bending of the immobilized cervical spine were analyzed in both groups using a wireless motion tracker system. RESULTS: A flexion of up to 19.0° was measured in the adult facial structure group. The mean flexion in the adult vs. geriatric facial structure groups were 14.5° vs. 6.5° (ranges: 9.0-19.0 vs. 5.0-7.0°), respectively. Thus, cervical spine motion was (p = 0.0286) significantly more reduced in the adult facial structure group. No (p = 0.0571) significant difference was oberserved in the mean lateral bending of the adult facial structure group (14.5°) compared to the geriatric facial structure group (7.5°). CONCLUSION: Emergency medical service personnel should therefore follow current guidelines and recommendations and perform cervical spine immobilization with a cervical collar, including in patients with a geriatric facial structure.

[The position of the head during treatment in the emergency room-an explorative analysis of immobilization of the cervical spine]. / Die Lagerung des Kopfes während der Behandlung im Schockraum ­ eine explorative Analyse über die Immobilisation der Halswirbelsäule.

BACKGROUND: Immobilization of the cervical spine is a standard procedure in emergency medicine mostly achieved via a cervical collar. In the emergency room other forms of immobilization are utilized as cervical collars have certain drawbacks. The present study aimed to provide preliminary data on the efficiency of immobilization in the emergency room by analyzing the residual spinal motion of the patient's head on different kinds of head rests. METHODS: In the present study biomechanical motion data of the cervical spine of a test subject were analyzed. The test subject was placed in a supine position on a mobile stretcher (Stryker M1 Roll-In System, Kalamazoo, MI, USA) wearing a cervical collar (Perfit ACE, Ballerup, Denmark). Three different head rests were tested: standard pillow, concave pillow and cavity pillow. The test subject carried out a predetermined motion protocol: right side inclination, left side inclination, flexion and extension. The residual spinal motion was recorded with wireless motion trackers (inertial measurement unit, Xsens Technologies, Enschede, The Netherlands). The first measurement was performed without a cervical collar or positioning on the pillows to measure the physiological baseline motion. Subsequently, three measurements were taken with the cervical collar applied and the pillows in place. From these measurements, a motion score was calculated that can represent the motion of the cervical spine. RESULTS: When the test subject's head was positioned on a standard pillow the physiological motion score was reduced from 69 to 40. When the test subject's head was placed on concave pillow the motion score was further reduced from 69 to 35. When the test subject's head was placed on cavity pillow the motion score was reduced from 69 to 59. The observed differences in the overall motion score of the cervical spine are mainly due to reduced flexion and extension rather than rotation or lateral inclination. CONCLUSION: The motion score of the cervical spine using motion sensors can provide important information for future analyses. The results of the present study suggest that trauma patients can be immobilized in the early trauma phase with a cervical collar and a head rest. The application of a cervical collar and the positioning on the concave pillow may achieve a good immobilization of the cervical spine in trauma patients in the early trauma phase.